Chronic pain is a national epidemic. Journalist Melanie Thernstrom, author of The Pain Chronicles, explains the difference between chronic and acute pain, how chronic pain rewires the brain, and the brain’s ability to modulate pain.
Dr. Stieg: Today I'm with Melanie Thernstrom, a journalist and author of several books including a New York Times Bestseller, The Pain Chronicles. She served on the National Academy of Science Institute of Medicine's Committee on Advancing Pain Research, Education and Care in response to a congressional mandate to investigate the state of pain treatment in the United States. Melanie, thank you so much for joining me.
Melanie Thernstrom: Oh, thank you for having me.
Dr. Stieg: I wanted to get into the differentiation between chronic pain and acute pain and specifically as it relates to your story in your book about how you experienced your pain and worked through it.
Melanie Thernstrom: I developed chronic neck and shoulder pain in my early thirties and I was very puzzled about this because before that I conceived of myself as someone who had a high pain threshold and that's because I was very accident prone and I did a lot of reckless sports skiing, horseback riding, always over my ability, and I had a lot of broken bones as well as I'm clumsy. And I found I was able to make the pain of the breaks go away temporarily. And this gave me the idea that I had a high pain threshold. I remember once I broke my arm on my way to a psychotherapy session and I thought I'd stop by my therapist's office and tell her I'd hurt my arm. And I was in graduate school, I was going to, the student health service. And I ended up staying for the whole hour. And I found by focusing on my emotional problems, the pain of what turned out to be a broken arm actually disappeared. So I didn't understand how I could then get chronic pain. And I began to research pain. I had an assignment from New York Times Magazine to write a piece about chronic pain. And what I discovered is that the brain has the ability to modulate acute pain, like the pain of a break.
Dr. Stieg: You were able to understand and manage the acute pain, but then what is it about the chronic pain that made it different and how you ended up managing that?
Melanie Thernstrom: What I discovered is that pain is ordinarily protective. It protects the body from tissue damage, but in situations of stress situations, when primitive man had his arm bitten by a tiger, you don't want primitive man standing around saying, "Ouch." And so the brain has the ability to shut down acute pain and give primitive man a high of endorphins and hormones so he can leap away pain-free from the tiger. And because that was a survival advantage that was perpetuated and we can tap into that survival advantage. It's called descending analgesia. If we have a, you know, an athletic feed, if we have a battle to fight or even if we have a very important psychotherapy session, our brain can hold off the pain and shut it down and then the pain comes back
Dr. Stieg: So it can do that for how long? Are we talking five minutes for an hour? Because again, chronic pain is something that is just unrelenting, not going to go away. So what's the time period for the descending analgesia?
Melanie Thernstrom: That's a good question. I am not positive of the precise time frame, but it is definitely limited to—
Dr. Stieg: The acute moment.
Melanie Thernstrom: And it lasts long in an acute moment, like maybe an hour, but it does not last a long time or it'd be a survival disadvantage because you need to rest that broken arm or allow your tissue to heal. Chronic pain is a very different thing because chronic pain, it turns out, is not protective. It may originally be caused by tissue damage or disease, but often that resolves and the pain continues and it's always been a great mystery, but there is now a body of evidence that chronic pain is in itself a disease. Chronic pain comes from damage to the central nervous system and the brain so that the pain goes on. It's experience to the person like it's indicating urgent alarm, tissue damage, but actually it's indicating nothing. It's just a broken alarm.
Dr. Stieg: This is where I think we need to be a little bit careful because there are organic reasons for chronic pain. An example would be the patient with rheumatoid arthritis. They've got terrible inflammatory disease in their joints, which is pain-inducing, but it's also chronic pain. And if we can treat the disease, we can hopefully treat the chronic pain versus the suffering that goes with that chronic pain. That's another component that can or cannot be treated and we're not necessarily so effective at treating it.
Melanie Thernstrom: Right. That's a very interesting point. You do have these pain causing diseases, but the interesting thing is that there is no fixed amount of pain. Someone with chronic rheumatoid arthritis needs to suffer. And in fact, if you talk to different patients, they suffer a great range of pain. Pain is not proportional to the disease and a majority of chronic pain patients actually never get a diagnosis. It's not actually clear of what the source of their pain is or the sorts of their pain has really healed long ago and the pain has gone on.
Dr. Stieg: That's the problem for the clinician, is you try to find the source of the pain and you can do innumerable tests with PET scanning and all the blood tests and MRI scans. Unlike you, who had some clear problems with your neck, correct? They identified some specific issues that was probably the cause of your pain?
Melanie Thernstrom: Yes, but again, it didn't, it doesn't determine the amount of pain, the amount of pain is much more a reflection of your brain and body's ability to modulate pain. They found that these problems, you know, on a scan, but there would be other patients who would have those problems on a scan who would have cervical spondylosis and osteoarthritis and other problems I have and they might say they're really not in pain.
Dr. Stieg: And then again, that's what makes the treatment of pain so difficult because it's not like a person who comes in with a ruptured appendix. You go in, you take it out and they all get better, you know? The variability between individuals makes it particularly challenging for the clinician trying to help treat that perception of the pain.
Melanie Thernstrom: Absolutely. In writing my book, I followed a group of about a hundred patients loosely for eight years. I observed their initial appointments with the pain specialists and then I stayed in touch with them loosely and saw, "Did they follow the recommendations, did they get bothered, did they get worse?" And one thing I really took away from it is you don't have to have a definite diagnosis in order to get better. And it's worth, because, very often it's not really known what in a diagnosis is really actually causing the pain. It's worth trying a whole bunch of pain treatments and seeing what works
Dr. Stieg: Well that's really the state of the art for pain management today is each patient unfortunately presents as their own clinical pain conundrum and you go through this battery and hopefully you find something that works for them. How common is, this? Is chronic pain an epidemic? Is it hundreds of millions of people? What did you find?
Melanie Thernstrom: The CDC estimates that about 50 million Americans have chronic pain and of those 8% or 20 million have high impact chronic pain, which is defined as pain that really, really affects them, really limits their life or work activities.
Dr. Stieg: What I'm interested in is, what impact did you find that this actually has on the brain? Are there changes in the brain that occur as a result of this chronic pain?
Melanie Thernstrom: Yes, that is one of the most frightening things about chronic pain is that the longer it goes on, the more it ends up rewiring the central nervous system and the brain in order to create more pain. It's like the pathways that transmit pain become ever more efficient and more cells are recruited to transmit pain and cells that are charged with modulating pain in both the brain and the spinal cord die out and pain specifically also seems to harm the cognitive parts of the brain. It causes much quicker degeneration in the gray matter of the brain than normal living does. They say living with chronic pain causes degeneration in one year that a person without pain would normally experience in two years.
Dr. Stieg: One thing I would think that would happen is if you're in chronic pain, your neurons, your nerve cells are always being stimulated and one might see a thickening in the sensory cortex, the area of the brain that is responsible for feeling. Does that occur?
Melanie Thernstrom: The instance I know that occurs in is in phantom limb pain when phantom limb pain is this very puzzling thing where people experience terrible pain coming from a limb that is no longer there. Like they'll experience cramping sensations in the hand when their hands are gone. And when they look at the sensory cortex, the part of the brain that maps that hand, they'll see that the amount of cells devoted to the hand you think they kind of die out because they're not getting that hand input and it would just be erased from the map of the body. But in fact they expand and begin to grow into other parts of the body. So you see these kind of pathological changes in the cells that are used to receiving the hand input and that appears to be very related to why they'll suddenly they'll be experiencing chronic pain in those missing limbs.
Dr. Stieg: Given all this complexity, the genetics, the cultural, the familial, and the physiological and psychological variability between each patient, what did you learn about the potential treatments for pain? Do you veer towards medication? Do you veer towards more psychological approaches? What's your general sense?
Melanie Thernstrom: I really think you have to do all of them. You have to attack chronic pain from all different angles. So there absolutely are effective medications in addition to opiates, which obviously can be very destructive. There are drugs that specifically treat nerve pain like nerve stabilizing drugs. Antidepressants work on pain. When they boost neurotransmitters like serotonin, those things actually modulate pain. A lot of times pain patients don't want to take antidepressants because they feel like, you know, I'm only depressed because I'm in pain. They feel they're being pathologized, but that's actually a misunderstanding because antidepressants modulate pain and pain causes depression. So almost everyone with chronic pain becomes, and the antidepressants also work in the animals modulate pain, the animals as well as humans. When I was writing my book, I often told pain patients that didn't want to take antidepressants and they found that like, strangely persuasive. They would say, "Oh, well if boosting serotonin in rats works, then, then I'm not being insulted by being asked to take those." Physical therapy is very important. Pain disrupts sleep, sleep can be treated.
Dr. Stieg: What about placebo? Everybody always talks about placebo.
Melanie Thernstrom: Placebo is a beautiful example of how the brain has the ability to modulate pain and one of the oldest medical papyrus is the Egyptian Ebers Papyrus — says that magic is effective together with medicine. And medicine is effective together with magic. And so they always used a plant remedy combined with a spell. And what we find is that you need to have the brain's own pain modulating capacities kick in as well as the drugs. When people are given opiates covertly like through the IV and they're not told, they are one-third less effective than if they are told you are being given a powerful pain-relieving agent and you will feel better soon.
Dr. Stieg: What about some of the ancient Chinese medicines or nutraceuticals? Do you think that's placebo? Is that a combination? What are your thoughts? Are they beneficial?
Melanie Thernstrom: First of all, almost anything can be beneficial if you believe it's beneficial and it can activate the brain's own pain system.
Dr. Stieg: So it's the mind over matter.
Melanie Thernstrom: I mean, I would say that formulation is, is really too simple because it's a very real thing that brain modulating pain. That's also matter, not, not just mind in some sense. I would say there's debate about it. Many researchers believe a lot of the power of acupuncture is placebo. Patrick Wall, a researcher, observed surgeries in China in the 70s being done only with acupuncture and he felt that the patients were basically in a trance and that they believe that the acupuncture would keep them from the pain of the surgery. And most of the time it did. And he observed a surgery where they started cutting before the acupuncture needles were in and the person was not hurt. Their brain had been told they wouldn't feel pain and their brain locked the pain out. And he came up with the theory that pain is a perception about an action that needs to be taken, not just a general perception. And if the brain believes you're not being hurt, then it thinks no action needs to be taken from that pain information coming from the body and it shuts it down.
Dr. Stieg: But we can manipulate the brains through things like distraction or using distraction therapy. That's, as I understand it from your book, that's also becoming more commonly used.
Melanie Thernstrom: Oh, absolutely. There are very interesting functional imaging studies showing the brain in action where you give someone a burning pain stimulus and then you ask them to do a counting task, and the brain just doesn't seem to gel to do two things at once very well. So they'll get very distracted by having to do the counting and you can see that pain activation in their brain dying down.
Dr. Stieg: Have you experienced or seen virtual reality therapy?
Melanie Thernstrom: Yes. I myself participated in a pain treatment. They called it neuroimaging therapy, where I was in a brain scanner and I was given a painful stimulus and in the scanner I saw a proxy of the pain activation in my brain. They had it in the form of flames and you would see it like flare up and die down and I've found just what they told me, which is that if you focus on seeing your pain as harmless as short term, you focus away from it. You can literally watch the pain activation in your own brain die down. They give you cues of how to make your pain flare up, like imagine causing longterm damage. Imagine that will never go away and you can see the pain flare up with these negative thoughts. And of course someone in chronic pain naturally has negative thoughts. They believe their pain will never go away.
Dr. Stieg: What about the individual, and this is something we all experienced, you know, we're getting ready to go to the dentist. We know that he or she might start drilling into our tooth. I have terrible anxiety with that. What can people do to modulate that or to affect their response?
Melanie Thernstrom: Fear of pain causes more pain. Again, in these brain imaging studies, you can see when people are told you are about to be given a painful stimulus, the pain activation will start before the stimulus even touches their skin. And so any kind of method to reduce anxiety will absolutely reduce the pain, whether it be antianxiety medication, whether it be talking to the dentist and forming a connection. Talking about the fear of that pain, being reassured that the anesthesia will be adequate using meditative techniques, self-hypnosis, guided imagery, anything to target the brain's ability to modulate that pain
Dr. Stieg: Through your personal experience, how have you reframed, individually, the way you think about pain?
Melanie Thernstrom: When I first had chronic pain, I had the idea that I wanted to be cured and there was like nothing less than a cure would make me happy otherwise my life was ruined. I could not abide having any pain at all and it was fixed in my mind that way and I, you know, certainly did attempt to find a cure, but most chronic pain can't be completely cured because it's already made changes in the brain and spinal cord that are self perpetuating. But pain can be managed and reduced. And what I found was when I accepted that I would have some pain and focused on reducing it to a manageable level and accepted that it was able to be reduced far enough in my consciousness that it no longer made me unhappy, that it was very much in the background. It's in the same way. I mean people can be a little bit hungry or a little bit cold and they're not miserable, but if you're too hungry or too cold, it becomes the first thing in your mind and it drives you mad.
Dr. Stieg: Let me ask you a question from a provider's perspective. You as a patient are a person that had chronic pain. Do you feel it's better for the provider to say, "I'm going to help you manage your pain? We might not be able to eliminate it completely, but we're going to get you to having a functional life versus initially being incredibly optimistic. Oh, don't worry, we're going to fix this and cure it." Again, it's a question of what's the appropriate expectation to set up in a person that has chronic pain?
Melanie Thernstrom: Wow, that is a very tricky question because you know you want to have the placebo benefit and so you could think, "Well, I'll tell them, you know, I promise I'm going to cure this and then you'll have the trust, you'll have the buy in, and then you'll have the placebo benefit. But the problem is that placebos often wear off with repeated use and then the patient may become very disillusioned and say, "You didn't cure my chronic pain" and then they're going to switch providers. I mean most chronic pain patients have seen an average of like 12 doctors or something like that because they continually realize that the doctor doesn't cure them and I have this experience myself where I would just, the doctor wouldn't cure me and I would switch doctors and so instead of, you know, really making use of the treatments that were offered, I was cure shopping. And cure shopping doesn't work with chronic pain most of the time.
Melanie Thernstrom: So I would say it's better to be somewhat realistic and say we're going to reduce your pain to very manageable level, but you also have to really bond with the patient. You have to tell the patient has to feel that the doctor is invested in their treatment, cares about their suffering, and wants them to get well. When I observe these doctor's appointments, the way that I did it is the doctor went in, you know at, at different medical clinics all over the country in hospitals. The doctor would go in with the patient first and say, "I'm being followed by a New York Times reporter. Is it okay if she comes in and observes the appointment?" And unless they work for the media, they would usually say yes. So then I would go in and I'd observed the appointment and then when the doctor left I'd asked questions to try to figure out how successful the appointment was.
Melanie Thernstrom: And one of the questions that I developed that really predicted how well the patient would do and whether they follow the treatment plan was, "Do you believe your doctor wants you to get well? And the patients who said, "Yes, absolutely. I know he really wants me to get better." They tended to follow the recommendations and many of them did get better. The ones who would kind of laugh and say, "Oh, I don't, I don't know. I don't know if he really cares that much one way or another." They wouldn't follow the plan and they find a new doctor who did care.
Dr. Stieg: You know, the patient has to be able to look us in the eye and trust the fact that we're actually there to try to help them. And that's done through eye contact, body motion and conversational form. And I, you know, I personally can't emphasize that enough.
Melanie Thernstrom: Yes, that is, that is absolutely the number one criteria for a doctor being successful.
Dr. Stieg: Melanie Thernstrom, I wanna express my appreciation for you taking the time to not only go through our understanding of pain, but also to reveal your personal story and how it changed the way you think about pain, the way you've had to live your life, and the impact I think your book is having on pain management in the United States. Thank you so much for being with us.
Melanie Thernstrom: Oh, thank you for having me.